10/7/2014

1

Quality Measurement’s Impact on

Public Reporting and Reimbursement

The IHI Triple Aim and NQS Three Aims

2

Improving the

patient

experience of

care

(including quality

and satisfaction)

Improving

the health

of populations

Reducing the per

capita cost of health

care

Better Care: Improve overall

quality by making health care

more patient-centered,

reliable, accessible, and safe

Healthy People/Healthy

Communities: Improve the

health of the U.S.

population by supporting

proven interventions to

address behavioral, social,

and environmental

determinants of health

AffordableCare: Reduce

the cost of quality health

care for individuals,

families, employers, and

government

Levers

National Quality Strategy “levers”: organizations’ core business

functions that serve as a means for improving health and health care quality

3

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2

The IHI Triple Aim and NQS Three Aims

4

Improving the

patient

experience of

care

(including quality

and satisfaction)

Improving

the health

of populations

Reducing the per

capita cost of health

care

Better Care: Improve overall

quality by making health care

more patient-centered,

reliable, accessible, and safe

Healthy People/Healthy

Communities: Improve the

health of the U.S.

population by supporting

proven interventions to

address behavioral, social,

and environmental

determinants of health

AffordableCare: Reduce

the cost of quality health

care for individuals,

families, employers, and

government

Perinatal Measures

• National Quality Forum

– Reproductive Health

– Pregnancy Care

– Childbirth

– Newborn Care

Quality Improvement

Provider Group

Practice Setting

Community

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3

The Health Care Quality Sea Shift

Value

Outcomes

Transparency

Medicare: Physician Quality Reporting System (PQRS)

Payment

Incentives

Feedback Reports

Multiple Reporting Mechanisms

Hundreds of Measures

Source: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-

Assessment-Instruments/PQRS/index.html

PQRS Measures of Interest to CNMs

• Elective Delivery or Early Induction Without Medical

Indication at ≥ 37 and < 39 Weeks (proposed for removal in

2015)

• Post-Partum Follow-Up and Care Coordination

• Pregnant women that had HBsAg testing

• Maternal Depression Screening

• Preventive Care and Screening: Tobacco Use: Screening and

Cessation Intervention

• Cervical Cancer Screening

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CNM Participation in PQRS - 2012

Five PQRS Measures Most Frequently Reported by CNMs (2012)

1. Health Information Technology (HIT): Adoption/Use of Electronic Health Records (EHR)

2. Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

3. Documentation of Current Medications in the Medical Record

4. Breast Cancer Screening

5. Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up

• In 2012, 602 of 1,810 potentially eligible CNMs

participated in PQRS.

• Among all eligible professionals, CNMs had the lowest

mean incentive payment.

Source: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-

Instruments/PQRS/Downloads/2012-PQRS-and-eRx-Experience-Report.zip

CNM Participation in PQRS - 2012

2012 PQRS Participation by CNMs

# CNMs

Receiving

Incentive

Payment

Percent of

Participating

CNMs Eligible

for Incentive

Percent of

all CNMs

Eligible for

Incentive

Minimum

Incentive

Amount

Median

Incentive

Amount

Mean

Incentive

Amount

Max

Incentive

Amount

Total

Incentive

Amount

539 89.5% 29.8% $0.10 $2 $7 $148 $3,895

• The 2012 incentive was +0.5%.

• The 2016 “adjustment” will be -2.0%.

• For CNMs, the costs of participating in PQRS

are likely to be much higher than the

“adjustments.”

Source: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-

Instruments/PQRS/Downloads/2012-PQRS-and-eRx-Experience-Report.zip

Medicare: Physician Value Based Payment Modifier

PQRS = Pay for

Reporting

PVBP = Pay for

Performance

Performance

Year

Payment

Modification

Year

Affected Providers Impact

2013 2015Physicians in groups with 100+

“eligible professionals”

-1% / possible increase.

2014 2016Physicians in groups with 10+

“eligible professionals”

-2% / possible increase.

2015 2017Proposed to impact all eligible

providers (includes CNMs)

Proposed

-4% / possible increase.

Source: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-

Payment/PhysicianFeedbackProgram/ValueBasedPaymentModifier.html

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The EHR Incentive Program and Meaningful Use

Medicare Program Medicaid Program

• Run by CMS • Run by state Medicaid agencies

• Max incentive $44,000 • Max incentive $63,750

• Payments over 5 consecutive years • Payments over 6 years, does not have to be consecutive

• Payment “adjustments” begin in 2015 for

eligible providers who do not participate

• No payment “adjustment” for providers only eligible for the

Medicaid program

• Must demonstrate “meaningful use” to

receive payment

• In the first year providers can receive an incentive payment for

adopting, implementing, or upgrading EHR technology.

Providers must demonstrate meaningful use in the remaining

years to receive incentive payments.

• Physicians and chiropractors are eligible • Physicians, NPs, CNMs, Dentists, some PAs are eligible

• CNMs must have a minimum 30% Medicaid patient volume or

practice predominantly in a Federally Qualified Health Center

or Rural Health Center and have a minimum 30% patient

volume attributable to needy individuals.

See: https://www.cms.gov/Regulations-and-

Guidance/Legislation/EHRIncentivePrograms/Downloads/EHR_Medicaid_Guide_Remediated_2012.pdf

The EHR Incentive Program and Meaningful Use

• In 2014, eligible providers must report on 9

“clinical quality measures,” which represent at

least three of the “National Quality Strategy”

domains.

“Meaningful

Use” =

Clinical Quality Measures of Interest to CNMs

• Preventive Care and Screening: Tobacco Use: Screening and

Cessation Intervention

• Cervical Cancer Screening

• Pregnant women that had HBsAg testing

• Maternal depression screening

• Preventive Care and Screening: Body Mass Index (BMI)

Screening and Follow-Up

• Closing the referral loop: receipt of specialist report

See: http://www.cms.gov/Regulations-and-

Guidance/Legislation/EHRIncentivePrograms/Downloads/EP_MeasuresTable_Posting_CQMs.pdf

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Medicare Physician Compare

List of All Medicare Providers

Address (with map)

Education

Group Affiliation

PQRS Reporting

ERxIncentive Reporting

Performance

on ACO Measures

The public can do

targeted searches,

or download the

entire database.

See: http://www.medicare.gov/physiciancompare/search.html

Release of Medicare Claims Data

• Medicare Provider Utilization and Payment Data: Physician and Other Supplier Public Use File– Medicare reimbursement data by National Provider

Identifier

– HCPCS Code

– Number of times each HCPCS code billed

– Number of beneficiaries receiving each service

– Medicare allowed amounts

– Billed charges

See: http://www.cms.gov/Research-Statistics-Data-and-

Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-

Data/Physician-and-Other-Supplier.html

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Release of Medicare Claims DataMedicare APRN Volume Experience 2012

CNSs CNMs CRNAs NPs

Min. Approved $45.00 $50.88 $102.93 $32.01

Max Approved $393,116.96 $103,809.08 $757,394.90 $2,920,792.77

Max Provider City Westfield, MA Prescott, AZ Bristol, TN Largo, FL

Median Approved $16,032.24 $1,619.04 $8,919.42 $12,915.62

Average Approved $28,011.92 $3,708.64 $16,029.16 $28,566.74

Max Beneficiaries 1,307 263 2,357 4,642

Median Beneficiaries 77 23 70 109

Average Beneficiaries 128 37 115 160

Min. HCPCS Codes 1 1 1 1

Max HCPCS Codes 32 17 28 76

Median HCPCS Codes 2 2 3 4

Provider Count 1,846 345 30,160 52,196

Medicaid Core Measure Sets

See: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Quality-of-

Care/Downloads/2014-Childrens-Report-to-Congress.pdf

and see: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Quality-of-

Care/Downloads/RTC_2014_Adult.pdf

Adult Measure Set

2012

• Adult Body Mass Index Assessment

• Cervical Cancer Screening

• Medical Assistance With Smoking and Tobacco Use Cessation

• PC-01: Elective Delivery

• PC-03: Antenatal Steroids

• Postpartum Care Rate

Child Measure Set

2012

• Cesarean Rate for Nulliparous Singleton Vertex (12 states reporting)

• Frequency of Ongoing Prenatal Care (25 states reporting)

• Live Births Weighing Less than 2,500 Grams (15 state reporting)

• Timeliness of Prenatal Care (31 states reporting)

26 States reported a median

of 18 adult measures in 2012.

Physicians – State Report Cards

See: http://www.hci3.org/sites/default/files/files/IssueBrief-Dec2013.pdf

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Accountable Care Organizations• Providers rewarded for improving quality and reducing

cost.– Medicare Shared Savings Program

(http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/index.html?redirect=/sharedsavingsprogram/)

• Measures depend on the program.

• More prevalent in the commercial world.– BCBSMA Alternative Quality Contract

(http://www.bluecrossma.com/visitor/about-us/affordability-quality/aqc.html)

The ultimate end of the ACO model is for providers to

take on risk, and that’s good for midwifery!

Hospitals – Inpatient Quality Reporting (IQR)

Hospitals must report on

specified quality

measures, or…..

The annual update in

their payments will be

reduced by 2%.

FY 2015 IQR measure of note for midwives: • For mandatory reporting –

• Elective Delivery Prior to 39 Completed Weeks Gestation

• For optional reporting –

• Exclusive breast milk feeding

• Health Term Newborn

CMS is likely to incorporate a measure of the rate

of cesarean surgeries in the near future.

Hospital Value Based Purchasing

IQR = Pay for

Reporting

HVPB = Pay for

Performance

See: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-

Instruments/hospital-value-based-purchasing/index.html?redirect=/hospital-

value-based-purchasing/

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Hospital Acquired Conditions and Readmissions

See: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-

Payment/HospitalAcqCond/Downloads/HACFactsheet.pdf

And see: http://cms.gov/Medicare/Medicare-Fee-for-Service-

Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html/

• Development of avoidable

conditions during a hospital stay

• Excess readmissions within 30

days of discharge

Bundled Payment for Care Improvement

Initiative (BPCI)

A single payment…. …for an entire episode of care.

• Currently focused on

post-acute care

• Performance

measurement will be

part of the equation

See: http://innovation.cms.gov/initiatives/bundled-payments/

Hospital Compare

See: http://www.medicare.gov/hospitalcompare/search.html?AspxAutoDetectCookieSupport=1

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Hospital Compare – Early Elective Deliveries –

Jan – Sept, 2013

• 2,440 hospitals reporting on this measure

• Minimum – 0%

• Median – 27%

• Mean – 5.9%

• Maximum – 96% (Bryan W. Whitfield Memorial Hospital, Demopolis, Alabama)

State Sponsored Hospital Report Cards

Cesarean Rates Among NY City Hospitals

www.myHealthFinder.com

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Private Entity Hospital Report Cards

The Bottom Line for Midwifery

• Providers who render low cost, high quality

care will benefit from reimbursement systems

that measure and reward quality.

• Make sure that the care you render is

attributed to you!

Q&A